June 4, 2010
The Honorable Kathleen Sebelius
Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
Mr. Jay Angoff
Director
Office of Consumer Information and Oversight
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, DC 20201
File Code: DHHS-9997-IFC
RE: Comments from the National Partnership for Women & Families on the Interim Final
Rule Detailing Health Care Reform Insurance Web Portal Requirements
Dear Secretary Sebelius and Director Angoff:
On behalf of the National Partnership for Women & Families, I want to commend and thank you
for your commitment to ensuring that the important consumer protections in the Patient
Protection and Affordable Care Act (PPACA) are implemented swiftly and effectively. The
National Partnership represents women and families across the country who are counting on
health reform to finally put in place a health care system that works for them. We believe that a
key component of health care reform is readily available and understandable information about
health insurance choices.
The recent interim final rule describes the requirements for an insurance Web portal through
which individuals and small businesses can identify affordable health insurance coverage
options in their State. We believe that, if done right, the Web portal will serve as an important
model for states as they establish their own Health Insurance Exchanges.
We are very pleased with the amount of attention that has been given to this rule, and the level
of detail it includes. It is clear that the Department of Health and Human Services (HHS)
recognizes the critical role the Web portal should play in informing consumers about what
options are available to them.
Nonetheless, there are a few areas where we believe the rule could be strengthened to ensure
that all Americans have access to meaningful information – in short, information that is both
comprehensive and comprehensible, including for people with limited English proficiency, low
health literacy, and disabilities.
1875 connecticut avenue, nw ~ suite 650 ~ washington, dc 20009 ~ phone: 202.986.2600 ~ fax: 202.986.2539
email: [email protected] ~ web: www.nationalpartnership.org
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Comprehensive Information
We appreciate the tremendous amount of information that must be collected, standardized, and
posted over the coming weeks and months. Nonetheless, there are some additional pieces of
information essential for consumers to make informed choices about affordable health
insurance that we encourage you to include online as soon as practicable.
•
Total Cost and Expected Premium Range. When comparing and considering
insurance plan options, it is critical for consumers to be able to predict how much they
can expect to pay. The inclusion of information on manual rates and cost sharing
options are important, but insufficient. We understand that it is not feasible to determine
individual premiums for underwritten coverage, but strongly encourage you to require
plans to offer an expected premium range for underwritten plans to better inform
consumers about the potential variation in premiums they could face. Please also clarify
the term “manual rate,” to ensure that the Web portal provides premiums adjusted for
age and, for health plans not subject to Section 1557 of PPACA, gender.1 In addition,
information about premium costs should be partnered with required cost-sharing to allow
consumers to estimate the total expected cost of coverage.
•
Benefits. Although women’s health care needs are not limited to reproductive health, it
is a key determinant of their overall health. Yet many insurance plans do not provide
comprehensive reproductive health care coverage. The Web portal should provide
women with detailed information about what reproductive health care services and
prescription drugs plans do and do not cover (i.e., contraception, gynecological
examinations, sexually transmitted infection (STI) screening, abortion care, infertility
services, maternity care, and cervical cancer screenings), along with the scope and
frequency of that coverage (e.g. whether contraceptive coverage is limited to particular
brands, generics, or methods).
Given the great variance in laws across the country regarding coverage of reproductive
health care services, the Web portal can and should play a critical role in educating
women about their legal rights and any restrictions on health benefits in their state. The
Web portal should provide consumers with information about state laws both mandating
benefit coverage (e.g. maternity coverage, or coverage of FDA-approved contraceptive
drugs and devices if prescription drug coverage is offered), and restricting or banning
coverage (e.g. prior to passage of PPACA, five states prohibited abortion coverage in
private health plans, except by separate rider).
•
1
Language Services. The growing foreign-born population in the U.S. has a profound
impact on our nation’s ability to provide quality health care to all its residents. Today,
there are more than 23 million Americans with limited English proficiency (LEP).2
Communication barriers can disrupt and delay care, leading to negative patient
experiences and outcomes, and to potentially higher costs due to less effective care
(more unnecessary tests, more emergency room visits, and less preventive care),
medical errors, and malpractice lawsuits.
Section 1557 of PPACA prohibits gender discrimination in federally funded activities or entities, except as otherwise
provided in PPACA.
2
Youdelman, Mara. “The Medical Tongue: U.S. Laws and Policies on Language Access.” Health Affairs, vol. 27, no.
2, 2008, pp. 424–433.
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For LEP individuals, knowing whether or not a health plan provides language services
can significantly impact their choice of plan. We urge you to include information on the
Web portal about whether or not plans provide language services and, if so, details
about the specific services offered.
•
Accreditation and Quality Data. We strongly disagree with your decision to allow but
not require plans to submit information on accreditation and quality. We believe this
information would be much more relevant to consumers’ interests than data on financial
rating, and would also be significantly more effective in engaging consumers in their
health care decisions. It is unacceptable that we expect consumers to take more
responsibility for health care decisions – and make more value-conscious decisions
about how to spend their health care dollars – but do not take the basic steps to enable
consumers to access information about both cost and quality. Further, not requiring the
coupling of cost and quality information exacerbates the problematic misperception on
the part of many consumers that higher costs necessarily correlate with better quality.
Health reform calls on individuals to share in responsibility for our health care system –
to do that, Americans need information about both cost and quality.
Insurance plans should be required to submit information on their accreditation status
and HEDIS and CAHPS scores. If plans are not accredited, they should still be required
to report on their performance on HEDIS and CAHPS or report the fact that they do not
currently measure quality. While a number of plans in the individual market will fall into
the latter category, this can and should encourage them to move toward quality
measurement. This information should be coupled with consumer-friendly educational
information about accreditation and quality measurement. For reference, the Office of
Personnel Management (OPM) offers a good model on the Federal Employees’ Health
Benefit Program’s (FEHBP) website
(http://www.opm.gov/insure/health/planinfo/accreditation.asp).
During the lag time between requiring plans to submit this information and its posting,
we would recommend that you link to currently publicly available information on plan
quality (e.g. state databases like that of California’s Office of the Patient Advocate). It
should also be required that the Web portal includes links to data on provider
performance (e.g. Hospital Compare, and the to-be-developed Physician Compare) to
compliment information on provider networks. PPACA calls for substantial investments
in making comparative quality data available to consumers – this is a central component
of the overall strategy to drive improvement in quality and enable consumers to make
better decisions. We cannot neglect this critical opportunity to facilitate consumers
accessing this important information.
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Additional Coverage Options. We are pleased that the Web portals will include
information about private plans, as well as Medicaid, CHIP, and high risk pools (both
traditional state high risk pools and the new, temporary high risk pools created by
PPACA). In addition, we would encourage you to include information about other statelevel public programs, such as Pennsylvania’s adultBasic and Washington’s Basic
Health programs. While these programs sometimes provide very limited benefits (and
should be clearly identified as doing so), for many individuals they may be the only
available coverage prior to 2014. We also urge you to include information about
Medicaid coverage offered through 1115 demonstration waivers – in particular, the
availability of coverage under family planning demonstration waivers.
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Comprehensible Information
The interim final rule sets out important guidelines for making the information it presents
comprehensible – minimizing “technical language, jargon, or excessive complexity,” and
providing information in a “consumer-friendly” format that is downloadable and repackage-able.
The rule also promises that HHS will conduct consumer testing to inform the development
process.
While these are important, high-level benchmarks, we believe detailed metrics must be
specified to ensure the Web portal delivers on its goals. Below, we offer some specific
recommendations that are essential to making the Web portal understandable to consumers. It
is important that more research be done to identify the kinds of information consumers need.
We would encourage HHS to expand its consumer testing, iteratively test the Web portal with
focus groups, and create consumer feedback mechanisms so the Web portal can continue to be
improved over time.
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•
Language Access. Millions of LEP Americans will only be able to experience the full
benefits of the Web portal if it is available to them in their primary language. To act in
accordance with Executive Order 13166, under which federal agencies are expected to
provide meaningful access to LEP individuals, HHS should ensure that the Web portal is
translated into at least the15 languages the Social Security Administration uses in the
language portal on its website.3 Links in the appropriate language to translated versions
should be clearly available on the homepage (or other entry point) of the Web portal. At
a minimum, if translations are not available, the Web portal’s homepage should include a
brief description in multiple languages explaining how and where to access the
information.
•
Disability Access. Over 50 million Americans have disabilities, including sensory (e.g.
low vision, blindness, and deaf-blindness) and intellectual disabilities, that could impede
their ability to utilize the Web portal. Not only will this limit their ability as individuals to
manage their own care, but would also limit the ability of many disabled parents and
caregivers to manage the care of their loved ones. We strongly encourage you to
ensure that the design and development of the Web portal follows standards for
disability access and that data displayed on the Web portal are in formats accessible
and easily usable by people with disabilities.
•
Meaningful Comparisons. Given the amount of information that will be included on the
Web portal, it could easily become overwhelming and unworkable for most Americans.
While most Americans champion the notion of “choice,” too much choice can sometimes
inhibit decision-making. We strongly support the options for limiting the number of plans
displayed, especially by provider network. We encourage you to also enable interactive
features so that consumers can sort and compare plans by quality metrics and
accreditation status. Quality information should be presented in an easy to understand
format, such as star ratings (e.g. the NCQA Health Plan Report Card), with links to find
out more information – including access to survey results (e.g. the Compare Health
Plans tool for the FEHBP on the OPM’s website).
Arabic, Armenian, Chinese, Farsi, French, Greek, Haitian-Creole, Italian, Korean, Polish, Portuguese, Russian,
Spanish, Tagalog, and Vietnamese.
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•
Consumer Input of Personal Data. The ability for consumers to receive detailed
information about their coverage options is an important feature of the Web portal, but
we are concerned that many consumers may have to provide detailed personal
information multiple times, particularly if they are trying to determine eligibility for public
programs like CHIP and Medicaid. We encourage you to look into methods that allow
consumers to only have to go through this process once.
Thank you again for this opportunity to comment on the Web portal. We are excited about the
potential it holds to engage and inform consumers about their health coverage options, and to
bring fresh competition to the insurance marketplace. The National Partnership for Women &
Families looks forward to working with you further on this initiative and on Health Insurance
Exchanges in the future, to help ensure that they are truly consumer friendly and patientcentered.
Sincerely,
Debra L. Ness, President